Myopic choroidal neovascularisation: current concepts and update on clinical management

Abstract

Choroidal neovascularisation (CNV) is a common vision-threatening complication of myopia and pathological myopia. Despite significant advances in understanding the epidemiology, pathogenesis and natural history of myopic CNV, there is no standard definition of myopic CNV and its relationship to axial length and other myopic degenerative changes. Several treatments are available to ophthalmologists, but with the advent of new therapies there is a need for further consensus and clinical management recommendations. Verteporfin photodynamic therapy has been an established treatment for subfoveal myopic CNV for many years, but this treatment does not restore visual acuity and is associated with long-term chorioretinal atrophy. More recently, clinical trials investigating the efficacy and safety of anti-vascular endothelial growth factor agents in patients with myopic CNV have demonstrated substantial visual acuity gains and quality of life increases compared with photodynamic therapy. These enhanced outcomes provide updated evidence-based clinical management guidelines of myopic CNV, and increase the need for a generally accepted definition for myopic CNV. This review critically summarises the latest myopic CNV literature in the context of clinical experience and recommends a myopic CNV treatment algorithm.

Keywords: Neovascularisation; Retina; Treatment Medical.

Figure 1

Differential diagnosis for myopic choroidal neovascularisation (CNV): (A and B) haemorrhage due to lacquer cracks; (C) dome-shaped macula with serous retinal detachment; and (D and E) macular fluid due to staphyloma.

Figure 2

Active myopic choroidal neovascularisation (CNV) imaged via (A) colour fundus photography; (B) fluorescein angiography; and (C) optical coherence tomography. (D) A fibrous pigmented scar (Fuchs’ spot). (E) Chorioretinal atrophy following regression of active myopic CNV.

Figure 3

Treatment algorithm for myopic CNV. *Ranibizumab is the only licensed anti-VEGF therapy for myopic CNV. Other anti-VEGFs (eg, bevacizumab and aflibercept) are not currently approved for myopic CNV. †Initiated with a single injection. ‡Monitoring for disease activity may include clinical examination, OCT or FA. If monitoring reveals signs of disease activity (reduced VA, blurred vision, metamorphopsia and/or lesion activity), further treatment is recommended. CNV, choroidal neovascularisation; OCT, optical coherence tomography; FA, fluorescein angiography; VA, visual acuity; VEGF, vascular endothelial growth factor.